NUTRITION AND NUTRITIONAL DISORDERSDR.S.CHAKRAVARTY

PROXIMATE PRINCIPLES

CARBOHYDRATES PROTEINS LIPIDS

CALORIFIC VALUE

ENERGY CONTENT OF FOOD MATERIALS 1 calorie is heat required to raise the

temperature of 1g water by 1 degree C .

•Protein: 4 calories per gram (16.8 joules/gram)

•Carbohydrate: 4 calories per gram (16.8 joules/gram)

•Fat: 9 calories per gram (37.8 joules/gram)

•Alcohol: 7 calories per gram (29.4 joules/gram)

RESPIRATORY QUOTIENT

RATIO OF VOLUME OF CO2 produced to O2 consumed CARBOHYDRATES = 1 FATS = 0.7 PROTEINS = 0.8

WHEN RATE OF UTILIZATION OF FATS INCREASE IN RELATION TO CARBOHYDRATES RQ FALLS eg Diabetes Mellitus

USMLE!!

BASAL METABOLIC RATE

BMR is defined as the energy required by an awake individual during physical , emotional and digestive rest . Note :- metabolic rate during sleep is less than BMR

Factors affecting BMR AGE = Period of active growth = High BMR . Old age = Low SEX = Males > Females Environment – BMR increases in COLD climate to maintain

body temperature EXERCISE = Increased BMR in people who are active

because of Increased cardiac output FEVER – 12% increase in BMR per degree centigrade

increase in body temp THYROID hormones – BMR increases in hyperthyroidism

and decreases in Hypothyroidism AVERAGE 24 Kcal/m2/hour

SPECIFIC DYNAMIC ACTION

This refers to increased heat production following intake of food (thermogenic effect of food ) Can think of this as the energy expenditure for

digestion and absorption of food SDA for proteins 30% SDA for lipids = 15 % SDA for carbohydrates = 5%

Hence for a mixed diet with roughly 60 % carbohydrates , 20%proteins and 20 % Lipids SDA = 10 % OF TOTAL CALORIES

BALANCED DIET A balanced diet is defined as “the one which

contains a variety of foods in such quantities and proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates and other nutrients is adequately met for maintaining health, vitality and general wellbeing and also makes a small provision for extra nutrients to withstand short duration of illness”.

PRESCRIPTION OF DIET – STEP 1 Ideal body weight is to be preserved

IDEAL BODY WEIGHT FOR AN AVERAGE ADULT MALE IS TAKEN AS 48KG FOR A HEIGHT OF 153 CM +/- 1.25 Kg for every cm

For females = 45kg for 153 cms +/- 1 Kg for every cm.

PROTEIN REQUIREMENT – 1g/Kg body weight

CALORIE REQUIREMENT – depends on age ,sex , height weight ,physical activity and occupation and health Rule of thumb 30(sedentary) – 35(moderate activities) kCal

PER KG BODY WEIGHT

Averages between 1700 – 3300 kCal /day for a person 55-65 kgs

Specific dynamic action = Add 10% of total calories

PRESCRIPTION OF DIET – STEP 1 REQUIREMENT OF PROXIMATE PRINCIPLES

If a person with body weight 60 kgs = 60 x 30(Kcal/kg) = 1800 Kcal

+ 10% SDA = 180 Kcal Total = 1800 + 180 = app 2000 Kcal

Protein requirement 1g/kg body weight so for 60 kgs = 60 g proteins , So energy from proteins = 60 x 4 = 240 So energy from CARBOHYDRATES PLUS FATS = 2000- 240 =

1760 Kcal 20 % of this energy should come from fats 1760 x 20%

= 350 Kcal So fats = 350 / 9 (calorific value ) = 39 g approx Rest should be from carbohydrates = 1760-350 = 1410 Kcal

So Carbohydrates required = 1410/4= 352 g carbohydrates

RULE OF THUMB = USE 30Kcal per kg body weight

CARBOHYDRATES

Complex carbohydrates are better as they are rich in dietary fibres and have low glycemic index.

GLYCEMIC INDEX The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100 according to the extent to which they raise blood sugar levels after eating.

GLYCEMIC INDEX

To determine a food's GI value, measured portions of the food containing 50 grams of available) are fed to 10 healthy people after an overnight fast.

Finger-prick blood samples are taken at 15-30 minute intervals over the next two hours.

These blood samples are used to construct a blood sugar response curve for the two hour period.

SUDDEN HIGH RELEASE OF INSULIN !

Low-GI foods, by virtue of their slow digestion and absorption, produce gradual rises in blood sugar and insulin levels, and have proven benefits for health.

Low GI diets have been shown to improve both glucose and lipid levels in people with diabetes (type 1 and type 2). They have benefits for weight control because they help control appetite and delay hunger. Low GI diets also reduce insulin levels and insulin resistance

DIETARY FIBRES

INCREASED BLOWEL MOTILITY DECREASED REABSORPTION OF BILE SALTS =

DECREASED CHOLESTEROL SATIETY – Sense of fullness after a meal

SUCROSE

Dyslipidemia Atherosclerosis ………..Why ? Obesity Why ? Dental caries

LIPIDS

VISIBLE FATS BUTTER , CHEESE ,OILS etc INVISIBLE FATS Eggs, Meat , Nuts etc

IDEAL INTAKE OF FATS = Upto 20% of total calories Out of which 25- 30% should be PUFA Cholesterol intake < 250 mg /day ~ 1 egg yolk

IDEAL COOKING MEDIUM = VEGETABLE OILS(Rich in PUFA and essential fatty acids )

Avoid animal fat butter etc as much as possible

INCORPORATE MORE OMEGA 3 FATTY ACIDS

PROTEINS

MALNUTRITION Malnutrition is defined as “ a pathological

state resulting from a relative to absolute deficiency or excess of one or more essential nutrients”.

Forms of malnutrition Undernutrion

- Protein Energy Malnutrition

- Anaemia

- Vitamin Deficiency

- Goitre Overnutrition

- Obesity

MARASMUS(Infantile Atrophy)

PROTEIN ENERGY MALNUTRTION OBESITY

KWASHIORKAR[PCM, Protein-Calorie (Energy) Malnutrition]

NUTRITIONAL DISORDERS

PROTEIN ENERGY MALNUTRITION

Most widespread nutritional problem.

PEM is a spectrum.

PEM is a range of pathological conditions arising from coincidental lack in varying proportions of proteins and calories occurring most frequently in infants and young children and commonly associated with infections.

PEM

improper and / or inadequate food intake

inadequate absorption of food

Deficient supply of food

poor dietary habitsfood faddism

emotional factors metabolic abnormalities

diseases

CAUSES OF PEM

CLINICAL INDICATORS FOR EVALUATION OF MALNUTRITION

Weight-for-age (underweight)

Height-for-age (stunting)

Weight-for-height (wasting)

Head circumference

Comparative measurements of mid-arm

circumference and skinfold thickness

Lab tests – serum proteins, albumin, transferrin,

prealbumin, etc.

- haemoglobin

- serum electrolytes

Immunologic deficiencies

WHO CLASSIFICATION OF MALNUTRITION

Type of PEM % of body wt. compared to standard weight

Oedema Deficiency in weight for height

Kwashiorkar 80 – 60 + +

Marasmic Kwashiorkar

< 60 + ++

Maramus < 60 Nil ++

Nutritional dwarfism

< 60 Nil Nil

Underweight 80 – 60 Nil Nil

CLINICAL MANIFESTATIONS

Failure to gain weight or loss of weight

Thin, subcutaneous fat reduced or despaired（ orderly abdomen, buttocks, limb and finally face）

Disturbances of functions of organs

MARASMUS(Infantile Atrophy, energy-deficiency

or energy-protein deficiency)

MARASMUS ( TO WASTE)

• Chronic Disorder

• Deficiency of ENERGY

•Deficiency of PROTEINS

• S/S -Growth Retardation- Anaemia- Fat and Muscle wasting- Starvation Adaptation- serum proteins and

electrolytes are within normal range – NO OEDEMA.

KWASHIORKAR

UNDER NUTRITION IN CHILDREN

KWASHIORKAR ( Sickness the older child gets, when the next child is born)

• Primary deficiency of PROTEINS.

• Adequate calorie intake

• S/S - Anorexia- Severe edema –

hypoalbuminaemia- Electrolyte disturbances- Fatty Liver

COMPARISON BETWEEN MARASMUS AND KWASHIORKAR

MARASMUS KWASHIORKAR

Age < 1 yr 1-5 yrs

Deficiency of Calorie Protein

Cause Early weaning & repeated infections

Starchy diet & acute infection

Growth retardation Marked Present

Attitude Irritable & fretful Lethargic & apathic

Appetite Normal Anorexia

Skin Dry & atrophic Exfoliation, desquamation – crazy pavement dermatitis

Hair Thin Sparse, thin hair, flag sign

Associated features Nutritional deficiencies, diarrhea, muscles- weak & atrophic

Angular stomatitis & cheiliosis, diarrhoea, muscle wasting

Serum albumin 2-3 gm/dl < 2gm/dl

BIOCHEMICAL ALTERATIONS

• BMR decreased

• Increased IgG

• Fatty Liver

• Hypoalbuminaemia

• Hypoglycaemia

• Hypokalaemia and Dehydration

• Hypomagnesaemia

TREATMENT

Diet – 150 – 200 kcal/Kg body weight and 2-3 gm protein / Kg body weight.

Treatment of acute problems – renal failure, shock, etc.

Treatment of dehydration. Antibiotics – for infections. Supplements – vitamin and minerals,

potassium. Iron and folic acid – to correct anaemia.

OBESITY Defined as an accumulation of excess fat in

the body.

Result of disturbed relationship between- input of energy- expenditure of energy- energy storage

ASSESSMENT OF OBESITY Body Mass Index

Body Weight BMI =

[Height (m)]2

Waist to Hip ratio> 0.9 in women, > 1.0 in men.

BMI Degree of Obesity

20 – 25 Normal

25 – 30 Overweight or Obesity Gr.I

30 – 35 Overobesity or Obesity Gr. II

Above 35 Gross Obesity or Obesity Gr. III

CLASSIFICATION Primary Secondary

CAUSES Metabolic - Excessive calorie intake

Hormonal – Hypothyroidism

- Hypogonadism - Hypopituitarism - Cushing’s syndrome

Genetic – mutation in leptin (Ob)gene

- familial hyperlipidaemias Environmental – relative abundance of food and

the type of food.

Appetite is influenced by many factors that are integrated by the brain, most importantly within the hypothalamus.

Signals that impinge on the hypothalamic center include

-neural afferents,

- hormones e.g. leptin, insulin, cortisol

- metabolites e.g. glucose, ketones.

- gut peptides e.g. CCK, PYY, Ghrelin

- psychological factors

- cultural factors

PATHOLOGIC CHANGES IN OBESITY Increased adipose tissue stores.

Increase in size and number of adipocytes.

Increase in TAG synthesis.

Hyperinsulinism.

Reproductive disorders – e.g. male hypogonadism( conversion of testosterone to estrogen in adipose tissue), PCOS.

Increased cholesterol and TG.

HEALTH RISKS

Atherosclerosis – cardiovascular diseases Insulin resistance Cholelithiasis Osteoarthritis Pulmonary disorders – decreased chest wall

compliance, increased work of breathing, decreased FRC & ERV, Sleep apnoea, Hypoventilation syndrome.

Cancers

TREATMENT Dietary Restriction

Increase energy expenditure- ACTIVE LIFE STYLE

Drug therapy - Sibutramine –anorexiant. - Orlistat- lipase inhibitor. -

- Fenfluramine – Phentermine( amphetamine)

Note about fen-phen combination - Fenfluramine has been associated with severe damage to heart

valves and pulmonary hypertension NOT USED NOW Phentermine is safer -

SURGERIES :- Surgery – liposuction Gastric banding

INFACT DECREASED CALORIE INTAKE IS ONE OF THE PROVEN THING S THAT ACTUALLY PROLONGS LIFE-SPAN IN HUMAN BEINGS ………

UNDER NUTRITION IN CHILDREN

THANK YOU!!

Each year, 2.6 million children die as a result of hunger-related causes…..

805 million people continue to struggle with hunger every day..

Never waste food ..…